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entitled 'Medicare Advantage: CMS Actions Regarding Plans' Health 
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GAO-10-953R: 

United States Government Accountability Office: 
Washington, DC 20548: 

September 20, 2010: 

The Honorable Joe Barton: 
Ranking Member: 
Committee on Energy and Commerce: 
House of Representatives: 

The Honorable Michael C. Burgess: 
Ranking Member: 
Subcommittee on Oversight and Investigations: 
Committee on Energy and Commerce: 
House of Representatives: 

The Honorable Greg Walden: 
House of Representatives: 

Subject: Medicare Advantage: CMS Actions Regarding Plans' Health 
Reform Communications: 

In August and September 2009, Humana--a large private health insurer-- 
sent a letter to the approximately 930,000 beneficiaries enrolled in 
its Medicare Advantage (MA) plans, advising that leading health reform 
proposals could adversely affect MA beneficiaries.[Footnote 1] Signed 
by Humana's Chief Medical Officer, the letter stated that if proposed 
funding cuts became law, "millions of seniors and disabled individuals 
could lose many of the important benefits and services that make MA 
health plans so valuable,"[Footnote 2] and encouraged beneficiaries to 
contact their members of Congress and ask them to protect MA funding. 
[Footnote 3] Once the Centers for Medicare & Medicaid Services (CMS) 
learned about the mailing,[Footnote 4] the agency directed Humana on 
September 18, 2009, and all other MA organizations on September 21, 
2009,[Footnote 5] to immediately stop all communications to 
beneficiaries about the potential impact of health reform legislation 
while CMS investigated whether such communications violated federal 
laws, regulations, or MA program guidance. CMS issued clarifying 
guidance to all MA organizations on October 16, 2009, and took 
compliance action against some organizations, closing its 
investigation. 

CMS is responsible for overseeing communications between MA 
organizations and beneficiaries enrolled in their plans. Because MA 
organizations are Medicare contractors, communications to 
beneficiaries must comply with various requirements, including 
marketing guidelines and restrictions on the use of beneficiary 
information obtained from CMS databases. CMS requires that MA 
organizations submit marketing materials--defined as materials 
targeted to beneficiaries that, among other things, provide 
information on plan benefits--to the agency for review and may impose 
penalties for distributing marketing material inappropriately. 
[Footnote 6] 

This report responds to your request that we review CMS's actions in 
response to MA plan communications to beneficiaries about pending 
health reform legislation. We examined: 

1. how CMS learned that Humana sent a mailing to beneficiaries on the 
impact of pending health reform legislation in 2009; 

2. the concerns CMS officials cited regarding the Humana material and 
the reasons they gave for suspending all MA plan communications about 
pending health reform legislation; 

3. how CMS learned whether any other MA organizations had communicated 
with enrolled beneficiaries about pending health reform legislation; 

4. what criteria CMS used to evaluate whether MA communications on 
pending health reform legislation violated any laws, regulations, or 
agency guidance; 

5. what CMS found in its investigation into MA communications on 
pending health reform legislation; 

6. what specific actions CMS took after it investigated MA 
communications; and: 

7. the extent to which CMS's actions were in accordance with agency 
policies and procedures, and consistent across MA organizations. 

To address these issues, we interviewed officials from CMS's central 
office and its Atlanta, Boston, Kansas City, New York, and San 
Francisco regional offices, as well as officials from the Department 
of Health and Human Services' (HHS) Office for Civil Rights. We also 
interviewed representatives from six MA organizations, including 
Humana, which CMS found to be noncompliant with regard to materials 
provided to beneficiaries on pending health reform legislation in 
2009. We reviewed relevant laws and regulations, CMS standard 
operating procedures, and other agency documentation related to its 
investigation into MA plans' communications to beneficiaries about 
pending health reform legislation. We conducted our work from April 
2010 through August 2010 in accordance with generally accepted 
government auditing standards. Those standards require that we plan 
and perform the audit to obtain sufficient, appropriate evidence to 
provide a reasonable basis for our findings based on our audit 
objectives. We believe that the evidence obtained provides a 
reasonable basis for our findings. 

1. How did CMS learn that Humana sent a mailing to beneficiaries about 
the impact of pending health reform legislation in 2009? 

According to CMS, during the third week of September 2009, officials 
from its Office of Legislation were on a phone call with a number of 
Senate staff discussing unrelated Medicare Advantage issues. At the 
end of that call, staff indicated they had reports from beneficiaries 
who had received mailings from their MA plan urging them to contact 
their members of Congress. Staff asked whether it was permissible for 
an MA organization to lobby the beneficiaries enrolled in their plans 
or ask beneficiaries to lobby Congress on the plan's behalf. The 
Office of Legislation referred the question to CMS's Center for Drug 
and Health Plan Choice, which is now the Center for Medicare. 
Subsequently, the Office of Legislation received and forwarded a 
number of additional inquiries from other congressional offices. 
Agency officials could not say with certainty which particular 
congressional office made the first inquiry.[Footnote 7] 

2. What concerns did CMS officials cite regarding the Humana material 
and what reasons did they give for suspending all MA plan 
communications about pending health reform legislation? 

On September 18, 2009, CMS instructed Humana to discontinue mailings 
containing its views on pending health reform legislation and to 
remove any related materials from its Web site while the agency 
investigated whether any federal laws, regulations, or MA program 
guidance had been violated. CMS's letter to Humana stated that: 

* the information contained in the mailing could mislead and confuse 
beneficiaries; 

* the mailing represented information to beneficiaries as official 
communications about the MA program; and: 

* the mailing potentially contravened federal laws, regulations, and 
guidance, including the Health Insurance Portability and 
Accountability Act of 1996 (HIPAA).[Footnote 8] 

Of particular concern to CMS was the statement on the mailing's 
envelope--"Important information about your Medicare Advantage plan - 
open today!" Agency officials noted in correspondence to members of 
Congress that such labeling on the envelope implied that the 
information provided in the Humana mailing was about the benefits 
offered under a particular plan.[Footnote 9] 

CMS cited similar concerns in its September 21, 2009, memorandum 
directing all MA organizations to immediately discontinue all 
communications on pending health reform legislation.[Footnote 10] The 
subject line for the September 21 memorandum read, "Misleading and 
Confusing Plan Communication to Enrollees." In it, CMS expressed 
concern that recent mailings by MA organizations claimed to convey 
legitimate program information about an individual's specific 
benefits, but instead offered opinion and conjecture about the effect 
of health reform legislation. Although they were aware only of the 
Humana mailing when they issued the September 21, 2009, memorandum, 
CMS officials told us they took this preemptive action to protect 
beneficiaries and avoid confusion while the agency investigated 
whether violations of federal laws, regulations, or MA program 
guidance had occurred. 

Furthermore, as CMS stated in its correspondence to members of 
Congress, the timing of the Humana mailing also raised concerns. 
Officials stated that beneficiaries could misconstrue it for their 
plan's annual notice of change--a letter describing any changes in 
coverage and costs for the upcoming year that MA organizations must 
send to beneficiaries by October 31 each year--rather than Humana's 
views on the implications of pending legislation.[Footnote 11] 
However, neither the September 18, 2009, letter to Humana nor the 
September 21, 2009, memorandum to all MA organizations expressed 
concern that the timing of these materials could cause them to be 
misconstrued with beneficiaries' annual notices of change. 

3. How did CMS learn whether any other MA organizations had 
communicated with enrolled beneficiaries about pending health reform 
legislation? 

To identify whether any other MA organizations communicated with 
beneficiaries on pending health reform legislation, CMS relied 
primarily on its regional offices. On September 21, 2009, CMS's 
central office provided the regional offices with information about 
the Humana mailing and told them to "be on the lookout" for similar 
communications from other MA organizations.[Footnote 12] Then, on 
September 24, 2009, CMS's central office directed the regional offices 
to examine plan marketing materials that had been submitted for CMS 
review in order to identify any health reform communication.[Footnote 
13] Also, some regional office staff contacted MA organizations to 
inquire whether they had disseminated materials on pending health 
reform legislation. Relevant materials were collected and 
preliminarily reviewed by regional office staff and then forwarded to 
CMS's central office for a final evaluation. Subsequently, CMS 
regional office staff learned of additional MA organizations' 
communications on pending health reform legislation during the normal 
course of business. For example, according to an MA organization we 
spoke with, CMS staff conducting a routine on-site audit noticed a 
newsletter in the company's reception area that contained information 
on health reform, which they forwarded to the central office. 

To supplement the regional office review, CMS engaged existing program 
management contractors to examine publicly available information to 
identify MA organizations' communications on health reform. The 
contractors looked at Web sites and placed telephone calls to customer 
call centers. They found several instances of organizations warning 
that health reform proposals threatened beneficiaries' coverage under 
the MA program. In their October 9, 2009, final report to CMS, the 
contractors indicated which MA organizations had used these outlets to 
encourage beneficiaries to contact members of Congress and object to 
program cuts. 

In addition, in October 2009, the Connecticut Attorney General, in 
conjunction with Connecticut's Office of the Healthcare Advocate, 
asked the state's five largest health insurers to submit any materials 
they disseminated on the impact of proposed reforms to the MA 
program.[Footnote 14] Three of the five organizations provided 
Connecticut officials with copies of information on pending health 
reform legislation either sent to beneficiaries or posted to their Web 
site. On October 29, 2009, Connecticut officials forwarded the replies 
to CMS and the congressional delegation from Connecticut. 

4. What criteria did CMS use to evaluate whether MA communications on 
pending health reform legislation violated any laws, regulations, or 
agency guidance? 

In responses to congressional correspondence following CMS's September 
21, 2009, memorandum, the agency reported that it is required by law 
and conforming regulations to ensure that (1) MA beneficiary 
communications are accurate and not confusing or misleading, (2) MA 
organizations do not use beneficiary information for purposes other 
than those agreed to under CMS's data use agreement that all MA 
organizations sign, and (3) federal funds are not used for 
impermissible activities, such as lobbying. Therefore, CMS explained, 
in its examination of MA organizations' documents, the agency sought 
to determine whether the MA organization had violated any of the 
following: 

* CMS's Medicare Marketing Guidelines prohibit MA organizations from 
disseminating misleading or confusing information.[Footnote 15] CMS 
explained that this covers instances where MA organizations 
inappropriately commingle plan and nonplan information in a single 
document, such as a member newsletter. In addition, the Medicare 
Marketing Guidelines require MA organizations to submit plan marketing 
materials--defined as "any informational materials targeted to 
Medicare beneficiaries that, among other things, provide information 
on plan benefits,"[Footnote 16]--to CMS for review prior to their 
distribution.[Footnote 17] 

* CMS's Data Use Agreement and related policies, which according to 
the agency, bar MA organizations from using Medicare beneficiary 
information obtained from CMS's databases for purposes other than the 
administration of plan benefits. MA organizations' use of beneficiary 
information for health-related communications, such as information on 
separate dental and vision policies,[Footnote 18] is consistent with 
the Data Use Agreement. However, MA organizations must obtain 
permission before using CMS's beneficiary information to send 
nonhealth-related information, such as information on life insurance 
policies and annuities.[Footnote 19] 

* Federal law prohibits the use of federal funds for certain 
activities designed to influence legislation or appropriations. 
[Footnote 20] Among the activities that cannot be paid for with 
federal funds are "grassroots" lobbying efforts aimed at defeating or 
supporting pending legislation that expressly urge the public to 
contact Congress. Contractors and grantees funded by annual HHS 
appropriations acts cannot use federal funds to pay for certain 
activities designed to influence legislation or appropriations pending 
before Congress. 

CMS's September 18, 2009, letter to Humana and September 21, 2009, 
memorandum to all MA organizations stated that some MA organizations' 
communications on pending health reform legislation had potentially 
violated HIPAA. However, the HHS Office for Civil Rights--the office 
responsible for enforcing the HIPAA Privacy Rule, which governs the 
use of individuals' protected information by health insurers and 
others--did not investigate whether MA organizations had violated 
HIPAA. According to an official in the Office for Civil Rights, 
because CMS was investigating whether MA organizations' communications 
violated the agency's Data Use Agreement, which the official stated is 
more restrictive than HIPAA on the use of beneficiary information, it 
was not necessary for the Office for Civil Rights to explore a 
potential HIPAA violation. 

5. What did CMS find in its investigation into MA communications on 
pending health reform legislation? 

CMS's investigation into MA communications found violations by 6 of 
the 189 MA organizations under contract with CMS in September 2009. 
[Footnote 21] These organizations used various means to communicate 
with about 3 million beneficiaries on pending health reform 
legislation. The agency concluded that four violated CMS's Medicare 
Marketing Guidelines, all six violated CMS's Data Use Agreement, and 
three violated the prohibition on using federal funds to lobby members 
of Congress on pending legislation.[Footnote 22] (See table 1.) 

Table 1: Results of CMS's Investigation of MA Organizations' 
Communications with Beneficiaries on Pending Health Reform 
Legislation, 2009: 

MA organization: A; 
Type of communication: Stand-alone mailing and article in newsletters; 
Month of communication: January, June, and September; 
Type of violation: CMS's Medicare Marketing Guidelines: [Check]; 
Type of violation: CMS's Data Use Agreement: [Check]; 
Type of violation: Legal prohibition on using federal funds for 
lobbying: [Empty]. 

MA organization: B; 
Type of communication: Flyer in plan "Welcome Kit;" 
Month of communication: February through September; 
Type of violation: CMS's Medicare Marketing Guidelines: [Empty]; 
Type of violation: CMS's Data Use Agreement: [Check]; 
Type of violation: Legal prohibition on using federal funds for 
lobbying: [Empty]. 

MA organization: C; 
Type of communication: Article in newsletters; 
Month of communication: March and June; 
Type of violation: CMS's Medicare Marketing Guidelines: [Empty]; 
Type of violation: CMS's Data Use Agreement: [Check]; 
Type of violation: Legal prohibition on using federal funds for 
lobbying: [Check]. 

MA organization: D; 
Type of communication: Article in newsletter; 
Month of communication: September; 
Type of violation: CMS's Medicare Marketing Guidelines: [Check]; 
Type of violation: CMS's Data Use Agreement: [Check]; 
Type of violation: Legal prohibition on using federal funds for 
lobbying: [Check]. 

MA organization: E; 
Type of communication: Article in newsletters; 
Month of communication: July and August; 
Type of violation: CMS's Medicare Marketing Guidelines: [Check]; 
Type of violation: CMS's Data Use Agreement: [Check]; 
Type of violation: Legal prohibition on using federal funds for 
lobbying: [Check]. 

MA organization: F; 
Type of communication: Stand-alone mailing; 
Month of communication: August and September; 
Type of violation: CMS's Medicare Marketing Guidelines: [Check]; 
Type of violation: CMS's Data Use Agreement: [Check]; 
Type of violation: Legal prohibition on using federal funds for 
lobbying: [Empty]. 

Source: CMS and MA organizations. 

Note: According to CMS, notices of noncompliance are considered 
confidential and are maintained in CMS's internal compliance tracking 
system, but not posted publicly. 

[End of table] 

All of the organizations cited by CMS had urged beneficiaries to 
contact members of Congress about pending health reform legislation 
directly or by referring them to the Coalition for Medicare Choices, 
[Footnote 23] an organization created by the industry trade 
association America's Health Insurance Plans. Four of the six MA 
organizations' materials directly stated that if health reform 
legislation was enacted, MA beneficiaries could experience reductions 
in their benefits. The other two MA organizations' materials did not 
directly mention the potential impact of pending health reform on plan 
benefits, but referred beneficiaries to the Coalition for Medicare 
Choices Web site, which stated that if Congress were to cut MA 
funding, "millions of seniors could see their benefits reduced, face 
higher out-of-pocket costs, or lose their MA coverage entirely." 

In addition, CMS found that three of the six MA organizations had not 
submitted their materials for agency review, as required by the 
Medicare marketing guidelines. These organizations told us that based 
on their interpretation of the guidelines, their communications did 
not meet the definition of marketing materials and were therefore 
exempt from the review requirement. For example, member newsletters 
are typically not subject to CMS review prior to use unless they 
convey information on enrollment, disenrollment, benefits or coverage, 
operational policies, rules, or procedures.[Footnote 24] One of the 
three MA organizations that had submitted their materials for CMS 
review told us they did so only as a precaution even though they did 
not consider them marketing materials. 

6. What specific actions did CMS take after it investigated MA 
communications? 

After determining that some MA organizations violated federal law, 
regulations, or MA program guidance, CMS took several actions. In a 
memorandum issued October 16, 2009, CMS provided clarifying guidance 
to amplify previous MA guidance on allowable uses of Medicare 
beneficiary information obtained from CMS. This guidance reiterated 
that the CMS Data Use Agreement--which all MA organizations must sign--
bars organizations from using CMS data for purposes other than the 
administration of plan benefits. In addition, the guidance clarified 
requirements in CMS's Medicare Marketing Guidelines pertaining to the 
use of beneficiary information for health care-related and nonhealth- 
care related lines of business. Specifically, the memorandum clarified 
that MA organizations are required to obtain prior authorization from 
beneficiaries in order to send them materials that are not health 
related. The October 16, 2009, guidance also stated that before 
distributing materials on pending state or federal legislation or 
about joining grassroots advocacy organizations, plans must ensure 
that beneficiaries have opted-in to receive such communications. 

Also on October 16, 2009, CMS issued another memorandum reiterating 
the prohibition on using federal funds for nonplan-related activities 
designed to influence legislation.[Footnote 25] The memorandum stated 
that MA and other organizations under contract with CMS may not 
include the cost of lobbying activities in their bid or cost reports. 
Furthermore, beginning with bids submitted for contract year 2011, if 
an agency audit were to determine that lobbying expenses had been paid 
with federal funds, the organizations would be required to return 
those expenditures to the federal government. 

Representatives from the MA organizations that we interviewed stated 
that, prior to the October 16, 2009, memoranda, in 1997 CMS issued a 
letter responding to an inquiry about a Medicare health maintenance 
organization's communications to beneficiaries on pending legislation. 
This letter, signed by the Director of the agency's Center for Health 
Plans and Providers,[Footnote 26] was, according to CMS, the most 
recent guidance issued by the agency on this issue and stated that a 
federal prohibition on such communication would violate the basic 
freedom of speech or other constitutional rights of Medicare 
beneficiaries. In responses to congressional correspondence, the CMS 
Acting Administrator noted that since 1997 many new laws and 
regulations have taken effect--including those related to data use, 
marketing, and health information privacy--that have implications for 
MA plans' communications on pending legislation. She pointed out that 
MA plans may communicate their views on pending legislation with no 
interference from CMS or others in HHS, provided it is done in 
accordance with CMS's current guidance. 

In addition, the agency issued letters of noncompliance--their lowest 
level of compliance action that carries no penalty--to five MA 
organizations in October 2009 and a sixth MA organization in June 
2010. CMS officials told us they decided to take this action in light 
of the somewhat vague guidance on this issue. At the time of CMS's 
review, the Marketing Guidelines did not explicitly address plan-to-
beneficiary political communications. Four of these MA organizations 
received noncompliance letters for violating both CMS's data use 
agreement and marketing guidelines and two organizations received 
noncompliance letters for violating CMS's Data Use Agreement. 

Finally, CMS stated in correspondence to members of Congress that the 
agency had asked several MA organizations that inappropriately used 
federal funds to reimburse Medicare for those funds. However, 
officials from the three MA organizations that used federal funds to 
communicate with beneficiaries on pending health reform legislation 
reported that they have not been asked to reimburse Medicare for 
federal funds used for such communications. CMS officials confirmed 
that, as of June 2010, they have not asked for reimbursement. 

7. To what extent were CMS's actions in accordance with agency 
policies and procedures, and consistent across MA organizations? 

In general, CMS's handling of MA communications on pending health 
reform legislation appeared to adhere to the agency's policies and 
procedures. For example, consistent with its operating procedures, CMS 
handled the inquiry about the Humana mailing in a manner and time 
frame typically used for congressional inquiries. CMS standard 
operating procedures state that all congressional inquiries are 
considered urgent and must be resolved within 10 days. Within a week 
of learning of the Humana mailing, CMS took action to address the 
matter. 

Some members of Congress expressed concern that the lobbying 
activities of AARP--an advocacy organization for people age 50 and 
older--were overlooked in the CMS investigation because it favored 
health reform legislation. However, we found that CMS reviewed all 
applicable MA organizations' communications in a consistent manner. 
While AARP receives royalties from UnitedHealthcare in exchange for 
the use of the AARP brand on some of its MA plans, it is not a 
Medicare contractor and maintains its own membership records. 
UnitedHealthcare, which offered an MA product co-branded under AARP, 
was included in CMS's investigation of health reform communications. 

Although CMS's actions generally conformed to its policies and 
procedures, the September 21, 2009, memorandum instructing all MA 
organizations to discontinue communications on pending legislation 
while CMS conducted its investigation was unusual. Officials from the 
MA organizations and CMS regional offices that we interviewed told us 
they were unaware of CMS ever directing all MA organizations to 
immediately stop an activity before CMS had determined whether that 
activity violated federal laws, regulations, or MA program guidance. 
When asked about this directive, officials from CMS's central office 
stated that, given the degree of potential harm to beneficiaries, the 
action was appropriate for the circumstances. 

Agency Comments and Our Evaluation: 

We obtained written comments on our draft report from HHS, the agency 
under which CMS operates, which are reprinted in enclosure I. HHS also 
provided technical comments, which we incorporated as appropriate. 

Regarding the Medicare Marketing Guidelines, HHS stated that not all 
instances of combining plan and nonplan information into a single 
document, such as a member newsletter, violate Medicare rules. In 
general, newsletters that contain information that qualifies as 
marketing material--such as information on benefits and coverage--are 
subject to Medicare review. HHS stated that although newsletters that 
contain marketing materials would not necessarily be disapproved, in 
certain instances CMS requires the separation of plan and nonplan 
information in mailings that might otherwise mislead beneficiaries. We 
modified language in the report to reflect this clarification. 

In addition, HHS expressed concern that our description of the 
September 21, 2009, memorandum as "unusual" makes it appear as though 
their suspension of all MA organizations' communications on pending 
health reform legislation was inappropriate. It noted that directing 
an MA organization to immediately stop an activity while the agency 
determined whether violations had occurred was infrequent but not 
unprecedented. It cited a previous instance where it suspended an MA 
reporting requirement while it reassessed its interpretation of 
regulations. We believe that the example provided--wherein CMS put its 
data collection activities on hold until the agency resolved concerns 
with interpretation of its own regulations--is not comparable to CMS 
instructing all MA organizations to stop sending information about 
health reform proposals to beneficiaries while it investigated 
potential violations. Moreover, our characterization of CMS's action 
as unusual is based on discussions with MA organizations and CMS 
staff. They told us that they could not recall a previous example 
where CMS told all plans to stop an activity after a potential 
violation was discovered and prior to the completion of an agency 
investigation. 

As agreed with your offices, unless you publicly announce its contents 
earlier, we plan no further distribution of this report for 30 days. 
At that time, we will send copies to the CMS Administrator and 
interested congressional committees. The report will also be available 
at no charge on the GAO Web site at [hyperlink, http://www.gao.gov]. 
Should you or your staff have any questions on matters discussed in 
this report, please contact me at (202) 512-7114 or cosgrovej@gao.gov. 
Contact points for our Offices of Congressional Relations and Public 
Affairs may be found on the last page of this report. Other key 
contributors to this report were Rosamond Katz, Assistant Director; 
Hillary Loeffler; Kevin Milne; Elizabeth Morrison; and Kathryn Richter. 

Signed by: 

James C. Cosgrove: 
Director, Health Care: 

Enclosure - 1: 

[End of section] 

Enclosure: Comments from the Department of Health and Human Services: 

Department Of Health And Human Services: 
Office Of The Secretary: 
Assistant Secretary for Legislation: 
Washington, DC 20201: 

August 30, 2010: 

James Cosgrove: 
Director, Health Care: 
U.S. Government Accountability Office: 
441 G Street N.W. 
Washington, DC 20548: 

Dear Mr. Cosgrove: 

Attached are comments on the U.S. Government Accountability Office's 
(GAO) report entitled: "Medicare Advantage: CMS Actions Regarding 
Plans' Health Reform Communications" (GAO-10-953R). 

The Department appreciates the opportunity to review this report 
before its publication. 

Sincerely, 

Signed by: 

Jim Esquea: 
Assistant Secretary for Legislation: 

Attachment: 

[End of letter] 

General Comments Of The Department Of Health And Human Services (HHS) 
On The Government Accountability Office'S (GAO) Draft Report Entitled, 
"Medicare Advantage: CMS Actions Regarding Plans' Health Reform 
Communications" (GAO-10-953R): 

The Department appreciates the opportunity to comment on this draft 
report. The report provides a summary of the Centers for Medicare and 
Medicaid Services (CMS) actions in response to Medicare Advantage (MA) 
organization communications to beneficiaries about pending health 
reform legislation in the fall of 2009. 

CMS took the actions described in this draft report under clear 
statutory and regulatory authority based on three underlying concerns 
regarding what CMS saw as potentially misleading or confusing plan 
mailings. First, under the statute and implementing regulations, CMS 
is required to ensure that communications from MA organizations to 
their MA plan enrollees about the MA plan are submitted to CMS for 
approval, and are accurate, and not confusing or misleading. Second, 
CMS must ensure that plans do not misuse beneficiary information for 
purposes inconsistent with the contractual and legal restrictions they 
have agreed to that pertain to the use of such information. Finally, 
CMS is required to ensure that Federal funds paid to contracting 
entities, including MA plans, are not used for impermissible purposes 
such as lobbying. Contracted organizations that sponsor Medicare 
Advantage and Part D plans may communicate their views on pending 
legislation without interference from CMS, but they must also comply 
with all relevant statutory, regulatory, and subregulatory 
requirements. 

While we agree that CMS' authority to prohibit plan sponsors from 
disseminating misleading or confusing information extends to instances 
in which MA organizations inappropriately co-mingle plan and non-plan 
information, we wish to clarify that MA organizations are not 
necessarily prohibited in all cases from combining plan and non-plan 
information in a single document, for example, a newsletter. 
Newsletters are not subject to Medicare review unless they contain 
information that meets the definition of marketing material (e.g., 
information on enrollment, disenrollment, benefits or coverage). While 
inclusion of benefit-specific information would subject a newsletter 
to our marketing material review requirements, this does not
necessarily mean the newsletter would be disapproved. However, there 
are various instances in the Medicare Marketing Guidelines where we 
require the separation of plan and non-plan information in mailings, 
including newsletters; on websites; and in advertisements with the 
express purpose of not misleading beneficiaries. In addition, our 
Guidelines require plan sponsors to pro-rate mailing costs when plan 
and non-plan information are co-mingled in a mailing to ensure the 
costs of non-Medicare materials were not included as "plan-related" 
costs in the plan sponsor's bid to CMS. 

In addition, we are concerned that the GAO's finding that our 
September 21, 2009 memorandum instructing all MA organizations to 
discontinue communications on pending legislation while CMS conducted 
its investigation was "unusual" makes it appear as though our actions 
were inappropriate. Given the potential for beneficiary confusion, we 
believed it was imperative to act quickly to avoid beneficiary 
confusion, particularly with the annual coordinated open enrollment 
period approaching. While infrequent, it is not unprecedented that CMS 
would direct MA organizations and Part D sponsors to immediately stop 
an activity while we determined whether actions were in violation of 
regulations or program guidance. For example, in July 2009, we asked 
MA organizations and Part D sponsors to suspend their submission of 
updated agent and broker commission fee information for contract year 
2010 enrollments (per a June 2009 instruction) while we considered 
whether we had appropriately interpreted our regulations with respect 
to compensation for initial enrollments. We subsequently (in August 
2009) reissued our policy and our request for resubmission of 
compensation amounts consistent with our regulatory authority. 

[End of section] 

Footnotes: 

[1] The MA program is an alternative to the original Medicare fee-for- 
service program. The MA program provides health care coverage to 
Medicare beneficiaries through private insurance plans, referred to as 
MA plans. MA plans must provide all Medicare-covered services (except 
hospice care) and may offer additional benefits and lower costs. As of 
December 2009, nearly 11 million--one in four--Medicare beneficiaries 
were enrolled in approximately 4,700 plans offered by 188 MA 
organizations. 

[2] Specifically, the benefits and services cited in the Humana 
mailing were low premiums, low deductibles and copayments, wellness 
and enhanced preventive benefits, and coordinated care and disease 
assistance programs. 

[3] The letter also invited beneficiaries and others to join a special 
Humana program--Partner--to receive information about proposed changes 
to Medicare and advocate for Medicare benefits and related issues. 

[4] CMS is the agency within the Department of Health and Human 
Services (HHS) that administers the Medicare program. 

[5] MA organizations may sponsor several MA plans with different 
benefits, cost-sharing requirements, and premiums. 

[6] See CMS, Medicare Managed Care Manual, Chapter 3 (Revised Aug. 7, 
2009). 

[7] On September 21, 2009, the Senate Committee on Finance issued a 
press release stating that the Committee Chairman had requested that 
CMS investigate the Humana mailing. 

[8] The Health Insurance Portability and Accountability Act of 1996 
(HIPAA) required the Secretary of HHS to issue regulations governing 
individually identifiable health information if Congress did not enact 
privacy legislation within 3 years of HIPAA's enactment. A final 
regulation implementing standards for the use and disclosure of 
certain health information, the "Privacy Rule," was published December 
28, 2000. Modifications to the Privacy Rule were published in final 
form August 14, 2002. See Pub. L. No. 104-191, §§ 261-264, and 45 CFR 
Parts 160 and 164, Subparts A and E. 

[9] According to CMS, between September 24, 2009, and October 13, 
2009, HHS and the agency received several inquiries signed by members 
of Congress. 

[10] The Senate Finance Committee began public debate of its health 
reform bill on September 22, 2009. 

[11] See Social Security Act § 1851(d)(2). 

[12] CMS requires MA organizations to submit all plan marketing 
materials to CMS prior to use. MA organizations can submit materials 
for CMS review under (1) the 45-day standard review process for 
material that does not contain, or contains modified, CMS model 
language; (2) the 10-day model review process for materials that use 
CMS model language without modification; or (3) the "file and use" 
process for marketing materials that have unmodified CMS model 
language and are submitted to CMS at least 5 days before distribution. 
MA organizations must certify that all plan materials submitted under 
file and use are in compliance with MA marketing requirements. 

[13] CMS conducts quarterly retrospective reviews of a sample of 
marketing materials submitted under the file and use process to ensure 
compliance with CMS marketing guidelines. This examination of 
marketing materials was not a part of a formal retrospective review 
that CMS conducts quarterly. 

[14] The five companies were Aetna, ConnectiCare, Anthem Health Plans 
of Connecticut, HealthNet of Connecticut, and UnitedHealth Group. 

[15] CMS, Medicare Managed Care Manual, Chapter 3, Section 40.5 
(Revised Aug. 7, 2009). 

[16] 42 CFR 422.2260; 423.2260. 

[17] CMS, Medicare Managed Care Manual, Chapter 3, Section 90 (Revised 
Aug. 7, 2009). 

[18] CMS, Medicare Managed Care Manual, Chapter 3, Section 40.14.1 
(Revised Aug. 7, 2009). 

[19] CMS, Medicare Managed Care Manual, Chapter 3, Section 40.14.5 
(Revised Aug. 7, 2009). 

[20] See, e.g., 18 U.S.C. § 1913; Departments of Labor, Health and 
Human Services, and Education, and Related Agencies Appropriation Act, 
2009, Pub. L. 111-8, 123, div. F, title V, § 503. 

[21] CMS identified an additional four organizations that had 
potentially violated federal laws, regulations, or MA program guidance 
on communications on pending health reform legislation. Agency 
officials told us that, prior to its investigation into MA 
communications, two organizations had asked regional office staff to 
review their materials and were advised not to disseminate the 
materials. During CMS's investigation, regional office staff 
determined that one MA organization developed newsletters that 
contained an article on health reform, and submitted them under the 
file and use process, but the organization told CMS it did not 
distribute them to beneficiaries; and another MA organization posted 
information on pending health reform legislation on a company Web site 
but not on its Medicare-specific Web site, and thus the communication 
was not deemed to be in violation of any federal laws, regulations, or 
MA program guidance. 

[22] CMS identified one of the six MA organizations from materials 
received from the Connecticut Attorney General's Office. CMS did not 
identify this organization during its own review because the 
organization did not submit its marketing material for CMS review. 

[23] The Coalition for Medicare Choices' Web site is available at: 
[hyperlink, http://www.medicarechoices.org]. 

[24] CMS, Medicare Managed Care Manual, Chapter 3, Section 90.20 
(Revised Aug. 7, 2009). 

[25] The clarifying information in the October 16, 2009, memoranda was 
subsequently incorporated into CMS's Medicare Marketing Guidelines. 
See CMS, Medicare Managed Care Manual, Chapter 3, Sections 160 and 170 
(Revised June 4, 2010). 

[26] In 1997, CMS was referred to as the Health Care Financing 
Administration. The Center for Health Plans and Providers is now 
referred to as the Medicare Drug and Health Plan Contract 
Administration Group. 

[End of section] 

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